Featured in This Issue:

Thai Study Finds PrEP Cuts HIV Transmission in Half Among Injection Drug Users:Pill-based pre-exposure prophylaxis (PrEP) reduced HIV transmission rates by nearly half in a group of Thai injection drug users, according to recently published findings from the Bangkok Tenofovir Study (BTS). On the strength of the BTS findings, the U.S. Centers for Disease Control and Prevention has updated its PrEP guidance to include injection drug users.

NMAC Issues New Report and Action Plan Focusing on HIV Among Black Gay and Bisexual Men: The National Minority AIDS Council (NMAC) has released a new report that provides an overview of the heavy burden of HIV on Black gay and bisexual men, and the factors that contribute to this burden. The report also provides a detailed action plan with nearly 40 recommendations to address the most pressing challenges posed by America’s criminal justice system, structural barriers to health care access, and the role that social determinants play in health outcomes.

UNAIDS Calls for an End to "Overly Broad" Criminalization of Non-Disclosure, Exposure, and Transmission of HIV: Late last month, the Joint United Nations Programme on HIV/AIDS (UNAIDS) published a 60-page guidance document calling for an end to "overly broad" criminalization of non-disclosure, exposure, and transmission of HIV. UNAIDS recommends that the application of criminal law in HIV/AIDS cases should: be guided by the best available scientific and medical evidence relating to HIV; uphold the principles of legal and judicial fairness; and protect the human rights of persons involved in criminal cases.

Chief Executives of HIV and LGBT Advocacy Groups Urge the LGBT Community to Re-Engage in the Fight Against HIV:The chief executives from 35 LGBT and HIV organizations have issued a joint letter committing themselves and their organizations to re-engaging the broader LGBT community in the fight against HIV. "The LGBT community always has been at the epicenter of the AIDS epidemic," noted Kate Kendell of the National Center for Lesbian Rights. "As the community most impacted in the nation, we are the ones who must step up and recommit to ending future transmissions."

Food Insecurity Linked to Higher Death Rates Among HIV-Infected Injection Drug Users: Food insecurity substantially increases the risk of death among HIV-infected IDUs even if they are receiving antiretroviral therapy, according to a recent study of more than 250 injection drug users in British Columbia, Canada. The study researchers found that, during a 13-year period, the drug users who were food insecure were nearly twice as likely to die compared to those who were food secure.

New and Worth Reading: New issue of the journal American Psychologist focusing on HIV health disparities, and a report claiming that the 2012 International AIDS Conference program lacked "meaningful coverage" of the populations most at risk for HIV.

News Roundup

Pill-based pre-exposure prophylaxis (PrEP) reduced HIV transmission rates by nearly half in a group of Thai injection drug users (IDUs), according to recently published findings from the Bangkok Tenofovir Study (BTS). This was the first study to show that PrEP can be effective in people who inject drugs. Earlier studies have found that PrEP can reduce the risk of sexual transmission of HIV among heterosexuals and men who have sex with men.

The BTS study included over 2,400 IDUs in Bangkok, Thailand. The study participants were randomly assigned into two groups of nearly equal size. The people in the PrEP treatment group received a once-daily dose of the anti-HIV drug tenofovir (sold in the U.S. under the trade name Viread), while those in the control group received a once-daily placebo pill. At monthly study visits, all participants were also offered extensive HIV education and risk-reduction counseling, methadone, HIV counseling and testing, condoms, and bleach with instructions on how to clean needles.

The BTS researchers found that, during the several-year study period, the number of new HIV infections in the placebo group totaled 33, compared with just 17 in the group receiving tenofovir-based PrEP. They calculated that the overall HIV infection rate was 49% lower in the tenofovir group. The BTS researchers also did a detailed analysis that took into consideration how consistently participants in the tenofovir group took their medication. They found that people with the best adherence to their daily PrEP regimen had an even lower HIV infection risk – a 74% reduction compared to the placebo group.

On the strength of the BTS findings, the U.S. Centers for Disease Control and Prevention (CDC) has updated its PrEP guidance to include IDUs. According to CDC, "Providing PrEP to IDUs at very high risk of HIV acquisition is likely to contribute to the reduction of HIV incidence in the U.S. In addition, if PrEP delivery is integrated with prevention and clinical care for the additional health issues faced by IDU (such as hepatitis B and C infection, abscesses, overdose), substance abuse treatment, and behavioral health care, and social services, it will contribute additional benefits to a population with multiple life-threatening physical, mental, and social health challenges."

It is worth noting that, in its guidance, CDC recommends that a two-drug pill be used for PrEP, rather than tenofovir alone, as was done in the BTS. The recommended two-drug pill contains both tenofovir and another anti-HIV drug called emtricitabine, and is sold under the trade name Truvada. Truvada is currently the only medication that the U.S. Food and Drug Administration has approved for PrEP.

"Unfortunately, Americans too often do not receive care they need, or they receive care that

causes harm." according to the National Healthcare Disparities Report 2012, which was published by the Agency for Healthcare Research and Quality (AHRQ) last month. Compared to previous years, the overall quality of U.S. healthcare is improving, according to AHRQ. Unfortunately, healthcare access is getting worse, and disparities in care are not improving. The report authors conclude that it will be necessary "to accelerate progress if the Nation is to achieve higher quality and more equitable healthcare in the near future."

The 250-page report provides a detailed review of health disparities in the quality of care provided and access to care for HIV/AIDS and 11 other health conditions and health services. In addition, it includes a chapter focusing on disparities in specific priority populations, including racial and ethnic minorities, low-income populations, older adults, residents of rural areas, and persons with disabilities or special healthcare needs.

Quality of Care: The report found that disparities in the quality of care were common in 2012:

Blacks received worse care than Whites, and Hispanics received worse care than non-Hispanic Whites for about 40% of quality measures.

American Indians and Alaska Natives (AI/ANs) received worse care than Whites for one-third of quality measures.

Asians received worse care than Whites for about one-quarter of quality measures but better care than Whites for a similar proportion of quality measures.

Poor and low-income people received worse care than high-income people for about 60% of quality measures; middle-income people received worse care for more than half the measures.

Access to Care: Disparities in access to care were also common, especially among AI/ANs, Hispanics, and poor people:

Blacks had worse access to care than Whites for one-third of measures, and AI/ANs had worse access to care than Whites for about 40% of access measures.

Asians had worse access to care than Whites for about 20% of access measures but better access to care than Whites for a similar proportion of access measures.

Hispanics had worse access to care than non-Hispanic Whites for about 70% of measures.

Poor people had worse access to care than high-income people for all measures; low-income people had worse access to care for more than 80% of measures, and middle-income people had worse access to care for about 70% of measures.

Regional Patterns: The report includes a series of maps with state-level data on several measures of healthcare quality: overall quality of care, primary care, acute care, and chronic care. In general, the New England states and upper Midwest ranked relatively high on each of these measures, while many – but not all – Southern states ranked low.

NMAC Issues New Report and Action Plan Focusing on HIV Among Black Gay and Bisexual Men

Early this month, the National Minority AIDS Council (NMAC) released a new report, RISE Proud: Combatting HIV Among Black Gay and Bisexual Men. The 35-page report provides an overview of the heavy burden of HIV on Black gay and bisexual men, and an in-depth look at three major factors that contribute to this burden:

high incarceration rates among young Black men and HIV criminalization laws;

social determinants, including substance use, poverty, discrimination, and homelessness, which place Black gay men at risk for infection and poor health outcomes; and

The report also provides a detailed action plan with nearly 40 "evidence-based recommendations to address the most pressing challenges posed by America’s criminal justice system, structural barriers to health care access, and the role that social determinants play in health outcomes," according to NMAC.

New HIV infections in young Black gay men rose 48% between 2006 and 2009, according to the report. Although Black gay and bisexual men make up less than 1% of the total U.S. population, they accounted for more than 22% of all new HIV infections. And in 2011, the estimated number of new HIV infections among Black gay and bisexual men for the first time surpassed the number of new infections among White gay and bisexual men. Previous studies have also shown that the health outcomes of Black gay men are significantly worse than those of their White counterparts.

"Black gay and bisexual men are incredibly resilient. But as a community, we have been let down by the public health system," NMAC Director of Legislative and Public Policy Kali Lindsey noted on the day the report was released. "Today’s report and the recommendations contained within are in no way a panacea, but we put forward a number of concrete steps that can be taken by all aspects of our society – from law enforcement to private funders, government agencies, to religious institutions – to improve our national response to this crisis. Our hope is that RISE Proud will begin the critical, and long overdue conversation about the intrinsic value of Black gay and bisexual men, and the need to demonstrate this through immediate and constructive action to mitigate the impact of HIV on all of us."

As a complement to the action plan, NMAC has launched a new website – www.BlackMenRISE.org – which provides plain-language resources to help Black gay and bisexual men manage their overall health, including sexual health.

UNAIDS Calls for an End to "Overly Broad" Criminalization of Non-Disclosure, Exposure, and Transmission of HIV

In late May, the Joint United Nations Programme on HIV/AIDS (UNAIDS) published a 60-page guidance document entitled, Ending Overly Broad Criminalisation of HIV Non-Disclosure, Exposure, and Transmission. Commenting on the new guidance, UNAIDS Executive Director Michel Sidibé noted that, "the overly broad criminalization of HIV non-disclosure, exposure, and transmission at best indicates a lack of understanding of the science of HIV, [and] at worst comprises an expression of discrimination against people living with HIV. Such overly broad laws not only lead to miscarriages of justice, but also threaten our efforts to address HIV in an effective and rights-based manner."

According to UNAIDS, the application of criminal law in HIV/AIDS cases should:

be guided by the best available scientific and medical evidence relating to HIV;

uphold the principles of legal and judicial fairness; and

protect the human rights of persons involved in criminal cases.

The HIV Justice Network has summarized key recommendations from the criminalization guidance, which have been adapted below:

In the absence of the actual transmission of HIV, the harm of HIV non-disclosure or exposure is not significant enough to warrant criminal prosecution. Non-disclosure of HIV- positive status and HIV exposure should therefore not be criminalized.

Where criminal liability is extended to cases that do not involve actual transmission of HIV, such liability should be limited to acts involving a "significant risk" of HIV transmission.

Any application of criminal law to HIV non-disclosure, exposure, or transmission should require proof, to the applicable criminal law standard, of intent to transmit HIV. Intent to transmit HIV cannot be presumed or solely derived from knowledge of positive HIV status and/or non-disclosure of that status and/or from engaging in unprotected sex, having a baby without taking steps to prevent mother-to-child transmission of HIV, or by sharing drug injection equipment.

Disclosure of HIV-positive status and/or informed consent by the sexual partner of the HIV-positive person should be recognized as defenses to charges of HIV exposure or transmission.

As with any crime, all elements of the offense of HIV non-disclosure, exposure, or transmission should be proved to the required criminal law standard.

Any penalties for HIV non-disclosure, exposure or transmission should be proportionate to the state of mind, the nature of the conduct, and the actual harm caused in the particular case, with mitigating and aggravating factors duly taken into account.

Countries should develop and implement prosecutorial and police guidelines to clarify, limit, and harmonize any application of criminal law to HIV. The development of such guidelines should ensure the effective participation of HIV experts, people living with HIV, and other key stakeholders.

Chief Executives of HIV and LGBT Advocacy Groups Urge the LGBT Community to Re-Engage in the Fight Against HIV

To mark the opening of Lesbian, Gay, Bisexual, and Transgender (LGBT) Pride Month, the chief executives from 35 LGBT and HIV/AIDS organizations issued a joint letter committing themselves and their organizations to re-engaging the broader LGBT community in the fight against HIV. The letter notes that, while the LGBT community has made great strides during the past 30 years in the movement toward full equality, "Unfortunately, our community hasn't maintained the same momentum in our fight against HIV." Despite the continued alarmingly high rates of HIV infection among gay and bisexual men and transgender women, attention to the HIV epidemic "has seemed to fall by the wayside. Many in our community have simply stopped talking about the issue. This must change."

The letter urges members of the LGBT community to take the following actions:

If you are a policy maker, fight to protect and expand HIV treatment and prevention programming and fight to stop HIV criminalization at the federal, state, and local level.

If you are an LGBT organization, be sure to speak to your constituents about the continued toll this epidemic has on our community.

If you're an LGBT donor, support causes that support the health of the community.

And, get tested, know your status, and join the fight to end this epidemic.

"The LGBT community always has been at the epicenter of the AIDS epidemic. As the community most impacted in the nation, we are the ones who must step up and recommit to ending future transmissions," noted Kate Kendell of the National Center for Lesbian Rights. "To have a new generation of LGBT young people grow up free from HIV and AIDS will be a fitting legacy to those we have lost to this disease."

Food insecurity substantially increases the risk of death among HIV-infected IDUs even if they are receiving antiretroviral therapy (ART), according to a new study in the journal PLoS One. The United Nations World Food Program defines food insecurity as having insufficient access to and adequate quantity and quality of food. In this study, researchers from the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE) and their colleagues studied the relationship between food insecurity and all-cause death rates among HIV-infected IDUs from across British Columbia who were starting ART for the first time. Of the 254 study participants, 71% reported being food insecure at the time they started ART.

During a 13-year follow-up period, the researchers found that drug users who were food insecure were nearly twice as likely to die compared to those who were food secure. Dr. Robert Hogg, director of the Drug Treatment Program at BC-CfE, noted that, although "the introduction of life-saving antiretroviral therapy has significantly reduced HIV-related morbidity and mortality. . . the impact of insufficient access to food, particularly quality food, on the mortality of HIV-positive injection drug users is alarming. This research points to the urgent need to further investigate the impact of food insecurity on the health outcomes of people living with HIV/AIDS."

Study coauthor Brian Chittock noted that, "Findings regarding the relationship between food insecurity and mortality are particularly relevant to community organizations working in Vancouver's Downtown Eastside, the epicenter of drug use in Canada." In addition, "The findings speak to the need to explore options for improving the quality of foods available to residents. Further, the results suggest drug users would benefit from improved access to education and counseling around healthy eating, nutritional screening, and referral for appropriate clinical care."

Coverage of Key Populations at the 2012 International AIDS Conference – This 48-page report by the Global Forum on MSM and HIV and other advocacy groups claims that the International AIDS Conference (IAC) program "continues to lack meaningful coverage of populations most-at-risk for HIV, including men who have sex with men, transgender people, people who inject drugs, and sex workers." According to the groups' analysis, only about one-sixth of the IAC abstracts focused exclusively on one or more of these high-risk groups.

Resources for National HIV Testing Day

This year, National HIV Testing Day will be held on Thursday, June 27. The theme for the 2013 campaign is "Take the test, take control." To help you, your clients, and at-risk communities prepare for and mark the day, we've compiled an annotated list of online resources focusing on HIV testing.

State HIV Testing Laws Compendium. Web page from the National HIV Clinician's Consultation Center. To get information about the laws in particular states, click on the U.S. map at the bottom of the page.